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Based on interview and record review the facility failed to provide stabilizing treatment by delivering the baby and placenta of a pregnant woman who presented at the hospital with ruptured membranes and having pain.

The patient was sent in her private vehicle to another hospital where she delivered her baby less than three (3) hours after she was released from the first hospital. Citing one patient named in a complaint (Patient #2).

Findings:

Review of complaint narrative revealed information the Patient (#2) arrived at Hospital (Q) on 10/17/2015 at 2:00 am with history of being discharged from Hospital (G) at 1:15 am on 10/17/2015 with instructions to go to Hospital (Q).

Hospital (Q) reported Patient (#2) was thirty eight and a half weeks pregnant with her second baby and had ruptured her membranes.

The patient was admitted and delivered a live infant on 10/17/2015 at 4:47 am (2 hours and 45 minutes after she arrived at the hospital and 3 hours and 30 minutes after leaving Hospital (G).

Review of OB (Obstetric) ED (Emergency Department) log dated 10/17/2015 at Hospital (G) revealed Patient #2 was logged in at 00:39 and logged out at 0050.

During a telephone interview on 12/16/2015 at 2:15pm with Dr. (#22), she gave the following information:

The patient came to the Labor and Delivery (L&D) suite with history that she thought she ruptured her membranes.

Dr. (#22) stated she evaluated Patient (#2) and she did rupture her membranes but she was not in active labor. The patient wanted to go to Hospital (Q) where her physician worked.

According to Dr. (#22) the patient was not in active labor so she discharged her with instructions to go and see her Obstetrician at Hospital (Q).

The Surveyor asked Dr. (#22) to define Active Labor and she explained that active labor is when the patient starts to dilate and the cervix begin to thin out or become effaced. She stated she would consider the patient in active labor when the patient is 90-100% effaced and 2-4 centimeters dilated.

Review of L&D nursing admission assessment notes dated 10/17/2015 at 00:58 revealed vital signs were within normal limits. Pain scale was 4/10 (10 being the worst pain). Vaginal examination revealed the patient was 1.5 cm dilated, 90% effaced, station (how far the baby's head is descended in the pelvis) at -2.

Nurses' notes documented Dr. (#22) at bedside, offered patient evaluation and admit if SPROM (spontaneous rupture of membrane) or evaluation and discharge if patient is stable. Patient choose to be evaluated and discharged if stable.

Nitrizine Paper (test for the presence of amniotic fluid) positive. Clear fluid noted on pad.

Review of Nursing Reassessment on 10/17/2015 at 1:06 revealed the patient was having mild contractions every 3-4 at 60 seconds duration, uterine irritability present.

Review of Nursing notes dated 10/17/2015 at 1:07 am revealed documentation that the patient was instructed on the need to go to Hospital (Q) at this time. Aware of SPROM and SVE (sterile vaginal examination).

Review of Physician progress notes dated 10/17/2015 at 1:51 am signed by Dr. (#22), Obstetrician, revealed the following information:

Nineteen (19) year old Patient (#2) was 38 weeks and 5 days pregnant with her second child. She was having contractions every 10 minutes and leaking clear vaginal fluid.

Patient (#2) is nitrizine (test for the presence of Amniotic fluid) positive, 1.5 cm 90% at -2 vertex with well applied head;

fetal heart rates average 130 beats per minute with good variability, and Blood Pressure is 111\67. Uncomplicated pregnancy. The patient really wants to go to Hospital (Q) so her doctor may care for her. "I will discharge her and she will be driven immediately to Hospital (Q)" (approximately 10 miles from Hospital (G)) .

Review of the patient's medical record at Hospital (G) revealed the patient was positive for ruptured membrane, was effaced 90% and was having contractions, however, she was not admitted and delivered her baby and placenta as required by hospital policy.

Review of delivery record for Patient (#2) from Hospital (Q) revealed the patient was admitted to the Obstetric Department on 10/17/2015 at 2:21 am and delivered a live infant on 10/17/2015 at 04:47 am (less than three hours after leaving Hospital (G)).

Review of the facility's Policy and Procedure PC/PS 0002 dated 6/1/2015 titled EMTALA and Patient Transfers, revealed the following information:

"This Policy and Procedure is based upon the federal law, Emergency Medical Treatment and Active Labor Act (EMTALA) and the Texas Administrative Code (TAC) regarding the medical screening, stabilization and treatment or Transfer of individuals between hospitals in an appropriate manner.

The procedure described in this Policy and Procedure will be observed whenever a hospital within Houston Methodist (Hospital or HM) is offering emergency medical services or transferring Patients to or from a Hospital. The treatment and Transfer of Patients with an Emergency Medical Condition (MEC) will not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition, economic status, insurance status or ability to pay.

Definition
Labor the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor".

From the admission assessment to the time of discharge instructions Patient (#2) was in Hospital (G) for under two hours.

Based on interview and record review the facility failed to provide a safe mode of transportation for a pregnant woman who had ruptured her membranes and was having pain, prior to sending the patient to another hospital for treatment. The patient was told to go "immediately" to the other hospital in her private vehicle;

The facility failed to contact the receiving hospital and confirm acceptance for care of the patient to ensure appropriate treatment was available, prior to sending the patient;

The facility failed to send the relevant patient information to ensure continuity of care and to minimize delay in treatment.

This failed practice had the potential for harm to the patient and unborn child. Citing one patient named in a complaint (Patient #2).

Findings:

Review of complaint narrative revealed Patient (#2) arrived at Hospital (Q) in her private vehicle on 10/17/2015 at 2:00 am with history of being discharged from Hospital (G) at 01:15 am on 10/17/2015.

The patient was admitted at Hospital (Q) and delivered a live infant on 10/17/2015 at 04:47 am (2 hours and 45 minutes after she arrived at the hospital and 3 hours and 30 minutes after leaving Hospital (G)).

Review of L&D nursing admission assessment notes dated 10/17/2015 at 00:58 revealed vital signs were within normal limits. Pain scale was 4/10 (10 being the worst pain). Vaginal examination revealed the patient was 1.5 cm dilated, 90% effaced, station (how far the baby's head has descended in the pelvis) at -2.

Nurses' notes documented Dr. (#22) at bedside, offered patient evaluation and admit if SPROM (spontaneous rupture of membrane) or evaluation and discharge if patient is stable. Patient choose to be evaluated and discharged if stable.

Nitrizine Paper (test for the presence of amniotic fluid) positive. Clear fluid noted on pad.
Review of Nursing Reassessment on 10/17/2015 at 1:06 revealed the patient was having mild contractions every 3-4 at 60 seconds duration, uterine irritability present.
Nursing documentation on 10/17/2015 at 1:07 am revealed documentation that the patient was instructed on the need to go to Hospital (Q) at this time. Aware of SPROM and SVE (sterile vaginal examination). Father driving patient.

Review of Physician progress notes dated 10/17/2015 at 1:51 am signed by Dr. (#22), Obstetrician, revealed the following information:
Nineteen (19) year old Patient (#2) was 38 weeks and 5 days pregnant with her second child. She was having contractions every 10 minutes and leaking clear vaginal fluid.

There was documentation the patient sees Dr. Unknown for her obstetrics care and thought he worked at Hospital (G) . Dr. Unknown only had privileges at Hospital (Q).

Patient (#2) wants to go there for her labor and delivery. She is nitrizine (test for the presence of Amniotic fluid) positive, 1.5 cm 90% at -2 vertex with well applied head; fetal heart rates average 130 beats per minute with good variability, and Blood Pressure is 111\67. Uncomplicated pregnancy. The patient really wants to go to Hospital (Q) so her doctor may care for her.

She is in stable condition, far from imminent delivery and there is no evidence of fetal compromise.
"I will discharge her and she will be driven immediately to Hospital (Q)" (approximately 10 miles from Hospital (G)).

Review of Discharge Instructions dated 10/17/2015 at 1:16 am revealed documentation "Patient desires to have baby where Dr. Unknown delivers. Understands the need to go to Hospital (Q) immediately as membrane is ruptured. Voiced understanding."

Review of OB (Obstetric) ED (Emergency Department) log dated 10/17/2015 revealed Patient (#2) was logged in at 00:39 with chief complaint of LOF (loss of fluid) and cramping. Her acuity was urgent.

Disposition was documented as "To go to TRH" (Hospital (Q)).

During an interview on 12/16/2015 with Dr. (#22) she gave the following information:

The patient came to the Labor and Delivery (L&D) suite with history that she thought she ruptured her membranes.

Dr. (#22) stated she evaluated Patient (#2) and she did rupture her membranes, but she was not in active labor. The patient wanted to go to Hospital (Q) where her physician worked.

According to Dr. (#22) the patient was not in active labor so she discharged her with instructions to go and see her Obstetrician at Hospital (Q). She stated the patient had ruptured her membranes and would need to go to the hospital at some point.

The Surveyor asked Dr. (#22) to define Active Labor and she explained that active labor is when the patient starts to dilate and the cervix begin to thin out or become effaced. She stated she would consider the patient in active labor when the patient is 90-100% effaced and 2-4 centimeters dilated.

Review of the facility's Policy and Procedure PC/PS 0002 dated 6/1/2015 titled EMTALA and Patient Transfers, revealed the following information:

"This Policy and Procedure is based upon the federal law, Emergency Medical Treatment and Active Labor Act (EMTALA) and the Texas Administrative Code (TAC) regarding the medical screening, stabilization and treatment or Transfer of individuals between hospitals in an appropriate manner. The procedure described in this Policy and Procedure will be observed whenever a hospital within the Houston Methodist (Hospital or HM) is offering emergency medical services or transferring Patients to or from a Hospital. The treatment and Transfer of Patients of Patients with Emergency Medical Condition (MEC) will not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition, economic status, insurance status or ability to pay.

Definition
Labor the process of childbirth beginning with latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor.

Appropriate Transfer of an individual with an EMC to another medical facility where:
The transferring hospital provides medical treatment within its Capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child;

The receiving hospital has available space and qualified personnel for the treatment of the individual, and has agreed to accept Transfer of the individual and to provide appropriate medical treatment;

The transferring hospital sends to the receiving facility all medical records (or copies) that are related to the EMC for which the individual presented and are available at the time of Transfer."